We just admitted a resident with two pressure injuries. The hospital had marked both as Stage 2. However, on admission to our facility, one presented with granulation tissue and the other had granulation and some thin slough in the wound bed. Are these Stage 2 pressure injuries?
No, neither of these pressure injuries is a Stage 2. According to the National Pressure Ulcer Advisory Panel (NPUAP), a Stage 2 pressure injury’s wound bed is viable, pink or red, moist in appearance, and without granulation tissue, slough, or eschar.
Stage 2 wounds heal by epithelialization: The skin migrates across the wound bed, which therefore does not produce granulation tissue.
A Stage 2 wound bed is pink or red, moist and smooth.
Also, if the hair follicle is still intact in a Stage 2, there will be epithelization from the follicle, creating little circular islands of epithelial tissue within the wound base.
Thus, your example presents healing Stage 3 or 4 wounds. Ensure your nurses are trained to accurately assess the type of tissue within the wound bed.
Even if the example wound has no depth and is flush with the skin, the wound was a Stage 3 or 4 at some point if there is any granulation tissue, slough or eschar.
Stage 3 or 4 granulation tissue is red, with a bumpy or granular appearance. Slough tissue is white or yellow and can be very thin, even transparent, or can become thick and stringy in consistency. Eschar is brown or black tissue. This is unlike a Stage 2 wound, which can produce a scab.
A scab is light brown or tan and appears to sit above the skin level, differing from eschar, which is black or dark brown and sits flush with or below the skin level.
From the October 2018 Issue of McKnight's Long-Term Care News
